Healthcare Provider Details

I. General information

NPI: 1588197628
Provider Name (Legal Business Name): ALLIANT THERAPY GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/05/2017
Last Update Date: 03/10/2025
Certification Date: 03/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 MAIN ST STE 104
EDMONDS WA
98020-3180
US

IV. Provider business mailing address

110 MAIN ST STE 104
EDMONDS WA
98020-3180
US

V. Phone/Fax

Practice location:
  • Phone: 425-361-7987
  • Fax:
Mailing address:
  • Phone: 425-361-7987
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLH60320548
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. CAROLYN RUSSO
Title or Position: OWNER
Credential: PHD
Phone: 425-361-7987